What have you been reading, hearing or TV viewing that has provoked some feelings of comfort or concern about what is happening in the world of medicine, medical care, treatment or science? Ethics is all about doing the right thing. Are you aware of any issues in medicine or biologic science which are being done right, could be improved or in fact represent totally unethical behavior?
Write about them here.. and I will too! ..Maurice (DoktorMo@aol.com)

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Saturday, February 05, 2011

Should a Dead Pregnant Woman’s Body be Preserved until Term Delivery of the Baby?

So consider this realistic scenario: a 23 year old woman is 3 months pregnant and suffers a massive brain hemorrhage which cannot be stabilized and the woman is pronounced dead on the basis of neurologic criteria (“brain dead”).On her driver’s license she permits, upon her death, for her organs to be removed for the use of transplant to a needy patient. She has never written an advance directive nor had prepared a legal Will.She has a husband, a mother and father and several siblings.There is chance, by prolonged intensive medical care, supporting her breathing, heart action and blood pressure and many chemical and endocrine changes that occur with death that her body can be preserved long enough for the fetus to be developed sufficiently so that it can be safely delivered into the world. And, at that time, organs can be removed for transplant. (Want to read how this has been done? Go to this link.) But who should give permission or deny permission to attempt to continue the pregnancy? If no prolonged support to the mother’s body is given and the fetus perishes, would this be considered an abortion?What if State law doesn’t allow for the fetus to die along with the mother and the State at this point assumes responsibility to direct the physicians to maintain the pregnancy? Who should pay the perhaps millions of dollars cost to continue the pregnancy? It would seem that the medical insurance company would not pay for preserving the body of a woman who was already pronounced dead.There are many other aspects to these real but rare scenarios, but first I would be interested to know what you think might be the right decision to be made...Maurice.

8 Comments:

The answer to the question asked in the title depends, in my opinion, on the gestational age of the fetus at the time of the mother's brain death. Three months, stated in your scenario, is not a gestational age where attempting to maintain the mother on artificial life support until the fetus reaches viability is a cost-effective or reasonable option. Not providing this support would not be considered a form of abortion, as the fetus depends directly and entirely upon the mother's body for support and at three months of gestational age would be a sort of extension of it rather than an independent (or potentially independent) being. (Interrupting a pregnancy intentionally is different than allowing a nonviable fetus to die when the mother does.) If the state has laws that say you cannot allow the fetus to die, then the state should eat the medical costs associated with maintaining life support until the fetus reaches viability. I would also suggest that it should be up to the family whether the pregnancy continues or not, if there is no such law. It would be a different scenario entirely if the woman in question was more than ~26 weeks pregnant, as this would be the point where some fetuses could be reasonably expected to survive if support was maintained and a cesarean was done at an appropriate time (say 34+ weeks).

When my grandfather went to medical school he was taught that life began at conception. When my father went to medical school he was taught that life began at conception. When I went to medical school suddenly they didn’t know when life began. So the answer to the questions posed by Dr Mo all depends on how you answer that question: When does life begin?

Gee, Anonymous, when your grandfather went to medical school he was taught that inducing seizures by chemical or electrical means was an acceptable treatment for a variety of psychiatric disorders; when your father went to medical school he may well have been taught that lobotomies were reasonable treatments to "cure" homosexuality--still an accepted treatment into the 1970s. So, with respect to your cute little homily on life beginning at conception, what's your point? That because pops and grandpops were taught Eternal Truths by the great medical scions that we have a simple answer to Dr. Mo's dilemma?

Oh, and last time I checked, back in the day of dad/granddad's medical schooling, nobody had the ability to keep a brain-dead woman at, say, 20 weeks gestation alive for months on end, so again I'm not sure the historical allusion is helpful.

It all depends o what she'd have wanted. I also wonder whether she's married or has a partner, and if so, it should be his business, or whoever will have to raise the child, to decide. The state shouldn't get involved, and if so doing, at its own expense. The problem is that it's very difficult to know what her exact plans would have been without a living will or other legal document. Perhaps close friends or relatives might have an idea of how exactly she would've dealt with the situation.

I understand your frustration with the historical allusion, since clearly many mistakes have been made in the medical field (as you pointed out), but I think Anonymous makes a valid case that you’re overlooking. If life begins at conception, then prolonged intensive medical care is as valid in this case for the fetus’ sake as it would be for the mother if she weren’t pronounced dead on the basis of neurologic criteria. However, if you say that life begins at the 26-week mark, the tables turn (for the argument’s sake at least) in this scenario.

There is a whole other unsettled debate regarding when life actually begins, and I doubt we’ll be able to resolve it over this forum. The question that I, like Anonymous, have is whether the patient’s family should cover the cost of the prolonged care, or the insurance company. What do you think?

To Billy Rubin I would like to say I think it is inappropriate to insult someone because they ask the question "When does life begin?" I mean come on who has never considered that question? And to insult the medicine of the past is ridiculous! The medicine of the past is the stepping stone on which our medicine is built; without it were would we be? I am sure future doctors will think we did moronic things too.

That being said I believe that, since there are so many individual feelings and ideas on the issue of when life begins, the choice should be the mother's. And since she would not be able to make the choice I would presume those close to her would know her well enough to make that choice for her.

I have two close friends that risked there lives to carry pregnancies they were told could kill them from day 1 (for 2 completely different reasons). I think they were nuts, but the moment they knew they were pregnant they loved whatever was in them. Whether it was a life now or in 9 months did not matter. Fortunately they and their children survived.

My point: I am pretty sure that being kept alive for their children to survive would have been worth any cost to them.

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